Free - Beyond Collapse

Saturday, April 5, 2014

SHTF Medicine - Baby Delivery in Austere Settings

In our last two articles, we discussed how (and why) to prevent
pregnancy in a long-term survival situation, as well as how to monitor a
pregnancy for complications throughout the entire nine months. Now it’s
time to discuss the actual physical process of delivery and how you, as
medic, can help deliver a healthy baby.

l begin to “drop”, assuming a position deep in the pelvis.
The patient’s abdomen may look different, or the top of the uterus (the
“fundus”) may appear lower. As the neck of the uterus (the cervix)
relaxes, the patient may notice a mucus-like discharge, sometimes with a
bloody component. This is referred to as the “bloody show” and is
usually a sign that things will be happening soon.

Examining a Pregnant Patient

If you examine your patient vaginally by gently inserting two fingers
of a gloved hand, you’ll notice the cervix is firm like your nose when
it is not ripe and soft like your lips when the due date is
approaching. This softening of the cervix is called “effacement”. As
time goes on, the sides of the cervix will thin out, until they are as
thin as paper.

Dilation of the cervical opening will be slow at first, and speed up
once you reach about 3-4 cm. At this level of dilation, you will be
able to place two (normal-sized) fingertips in the cervix and feel
something firm; this is the baby’s head.

Contractions will start becoming more frequent. To identify a
contraction, feel the skin on the soft area of your cheek, and then
touch your forehead. A contraction will feel like your forehead. False
labor, or Braxton-Hicks contractions, will be irregular and will abate
with bed rest, especially on the left side, and hydration. If
contractions are coming faster and more furious even with bed rest and
hydration, it may just be time to have a baby! A gush of watery fluid
from the vagina will often signify “breaking the water”, and is also a
sign of impending labor and delivery. The timing will be highly
variable.
The delivery of a baby is best accomplished with the help of an
experienced midwife or obstetrician, but those professionals will be
hard to find in a collapse situation. If there is no chance of
accessing modern medical care, it will be up to you to perform the
delivery.

To get ready for delivery, wash your hands and then put gloves on.
Then, set up clean sheets so that there will be the least contamination
possible. Tuck a sheet under the mother’s buttocks and spread it on
your lap so that the baby, which comes out very slippery, will land onto
the sheet instead of landing on the floor if you lose your grip on it.
Place a towel on the mother’s belly; this is where the baby will go
once it is delivered. It will be very important to dry the baby and
wrap it in the towel, as newborns lose heat very quickly. Newborns are
also susceptible to infection, so avoid touching anything but mother and
baby if you can.

Baby Delivery

As the labor progresses, the baby’s head will move down the birth
canal and the vagina will begin to bulge. When the baby’s head begins
to become visible, it is called “crowning”. If the water has not yet
broken (which can happen even at this late stage), the lining of the bag
of water will appear as a slick gray surface. Some pressure on the
membrane will rupture it, which is okay at this point. It will help the
process along.
To make space, place two gloved fingers in the vagina by the
perineum. This is the area between the vagina and anus. Using gentle
pressure, move your fingers from side to side. This will stretch the
area somewhat to give the baby a little more room to come out.

With each contraction, the baby’s head will come out a little more.
Don’t be concerned if it goes back in a little after the contraction.
It will make steady progress and more and more of the head will become
visible. Encourage the mother to help by taking a deep breath with each
contraction and then pushing while slowly exhaling.

On occasion, a small cut is made in the bottom of the vagina to make
room for the baby to be delivered. This is called an “episiotomy”. I
discourage this if at all possible, as the cut has to be sutured
afterward. I always make this decision as the head is crowning.
As the baby’s head emerges, it will usually face straight down or up,
and then turn to the side. The cord might appear to be wrapped around
its neck. If this is the case, gently slip the cord over the baby’s
head. In cases where the cord is very tight and is preventing delivery,
you may have to doubly clamp it and cut between. This will release the tension.Next, gently hold each side of the baby’s head and
apply gentle traction straight down. This will help the top shoulder out
of the birth canal. Occasionally, steady gentle pressure on the top of
the uterus during a contraction may be required if the mother is
exhausted. Once the shoulders are out, the baby will deliver with one
last push. The new mother can now rest.

Put the baby immediately on the mother’s belly and clean out its nose
and mouth with a bulb syringe. It will usually begin crying, which is a
good sign that it is a vigorous infant. Spanking the baby’s bottom to
get it to cry is rarely needed, and is more of a cliché than anything
else. A better way to stimulate a baby to cry is to rub the baby’s
back.
Dry the baby and wrap it up in a small towel or blanket. Clamp the
cord twice (2 inches apart) with Kelly or Umbilical clamps, and cut in
between with a scissors. Delivery kits are available online with
everything you need, including drapes, clamps, bulb syringes, etc.
Once the baby has delivered, it’s the placenta’s turn. Be patient: In
most cases, the placenta will deliver in a few minutes. Pulling on the
umbilical cord to force the placenta out is usually a bad idea.
Breaking the cord due to excessive traction will require your placing
your hand deep in the uterus to extract it, which is traumatic and can
introduce infection. You can ask the mother to give a push when it’s
clear the placenta is almost out. If traction is necessary for some
reason, place your fingers above the pubic bone and press as you apply
mild traction. This will prevent the uterus being turned inside out (a
potentially life-threatening situation) if the placenta is stubborn. A
moderate amount of bleeding is not unusual afterwards.

Once the placenta is out, examine it. The “fetal” surface is grey
and shiny; turn it inside out and you will see the “maternal” surface,
which look like a rough version of liver. The fetal surface is
separated into compartments called “cotyledons”. If a portion of the
placenta remains inside, you may have to extract it manually. The
maternal and fetal surfaces, respectively, are shown in the images
below:

Manual Extraction (very uncomfortable)
The uterus (the top of which is now around the level of the belly
button) contracts to control bleeding naturally. In a long labor, the
uterus may be as tired as the mother after delivery, and may be slow to
contract. As a result, this may cause excessive bleeding. Gentle
massage of the top of the uterus (known as the “fundus”) will get it
firm again and thus limit blood loss. You may have to do this from time
to time during the first 24 hours or so after delivery.

Place the baby on the mother’s breast soon after delivery. This will
begin the secretion of “colostrum”, a clear yellow liquid rich in
substances that will increase the baby’s resistance to infection.
Suckling also causes the uterus to contract; this is also a factor in
decreasing blood loss. Monitor the mother closely for excessive bleeding
over the next few days. In normal situations, the bleeding will become
more and more watery as time progresses. This is normal. Also, keep
an eye out for evidence of fever or other issues.
Human pregnancy and delivery is a natural process and, usually,
proceeds in an uncomplicated manner. Learning to help the process along
and identifying problems will give you the best chance of bringing a
healthy baby (from a healthy mother) into the world. Even in a survival
situation, seek out experienced professionals that can help.